Child Registration Form

Please complete this form to the best of your ability.

Child Registration

TRINITY PSYCH WELLNESS

Person Completing This Form

Provide your details.

First Name

Last Name

Your Email

Relationship to child

Today's Date

CHILD'S INFORMATION

Name of child

Child's date of birth: Day/Month/Year

Child's Age

Child's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

CONTACT INFORMATION

Provide phone numbers where we may contact or leave a message.

1. Contact

Main person to contact

First Name

Last Name

Home Phone

Relationship to child

Work Phone

2. Contact

Second contact

First Name

Last Name

Home Phone

Relationship to child

Work Phone

3. Emergency Contact

In case of an emergency, if the above two contacts cannot be reached.

First Name

Last Name

Home Phone

Relationship to child

Work Phone

Financial Contact

The person responsible for the child's therapy service or financial agreement.

First Name

Last Name

Phone/Mobile

Financial Party Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

FAMILY HISTORY

Details about the child's family.

Who is the child living with - select

Status of parents relationship - select

If divorced - for how long

If Other - Provide Name

If married - for how long

If divorced - child's age at divorce

RELATED TO PARENT'S DIVORCE

A copy of court documents is required and will be a part of the child's file.

Legal Custody is 50/50 - select

MOTHER

Last Name

How is child's time divided - explain

If NO, Primary Legal Parent

FATHER

Last Name

HOUSEHOLD MEMBERS

List all children and adults who live in the child's home. Add a new line for each member.
Please include: name, age, sex, and relationship to child. Example:
Bob, age 6, male, younger brother.
Jane, age 15, female, older sister.

Members of child's current living situation.

MEDICAL HISTORY

Please provide child's medical history as known.

Paediatrician/Family Physician - Name:

Phone

Has your child been taken to the emergency room, hospitalized, or had outpatient surgery since birth?

YES

If Yes, provide details. Example: List at what age, reason and result.

Has your child had a head injury?

YES

Did your child lose consciousness?

YES

If yes, note how many times

If yes, note how injury happened

Has your child been diagnosed with a chronic health condition?

YES

If Yes, provide details: Name of condition, who diagnosed and when (age of child at the time).

Does your child take medication on a daily basis?

YES

If Yes, provide name of medications and details.

EDUCATION HISTORY

Details about school(s) and learning skills.

Name of current school

Do you feel your child is learning up to his or her's potential?

Yes

Child's current grade level

If no, indicate the academics that are underdeveloped:

List any extracurricular activities your child is currently a participant of in school or outside of school - example: In school - band, plays flute. Outside school - Soccer team for 8-10 year-olds.

Has your child been retained a grade?

Yes

If yes, which grade number

ACADEMIC CONCERNS

Below is a list of concerns or problems, please check all that you feel applies to your child.

Check all that apply

Does not do homework

Gets distracted easily

Forgets assignments

Has trouble staying seated

Noncompliant in class

Excessive talking

Poor attention in class

Fidgets/Squirms

Can't play or relax quietly

Blurts out answers

Difficulty awaiting turn

Check all that apply

Excessive time to complete tasks

Poor handwriting

Test anxiety

Starts but doesn't finish homework

Incomplete classroom work

Messy/disorganized

Make careless errors/ignores details

Runs/climbs excessively / restless

Feels "on the go" / driven by a motor

Interrupts / Intrudes

Difficulty awaiting turn

Child has a learning disability?

Yes

Child has a language disability?

Yes

If yes, what subjects

If yes, what type

If yes to learning or language disability, who provided the diagnosis and how old was your child when diagnosed?

Does your child currently have a...

IEP

504

Other health impaired services

Please describe

Early Development

Birth, Infancy, and Early Childhood Development History

Medical problems during pregnancy?

Yes

Please describe

Medications taken during pregnancy?

Yes

Please describe

Substances used during pregnancy

Please provide details.

Check all that apply

Cigarettes

Alcohol

Other drugs

Depending on your answer, provide details. Example: How many cigarettes/drinks, how often, other drugs.

EARLY BEHAVIOR

Please check all of the behaviors that best describe your child during infancy and early childhood.

Check all that apply

Quiet and content

Very easy to feed

Slept well

Usually relaxed

Under active

Cuddly, easy to hold

Easily calmed down

Cautious and careful

Coordinated

Enjoyed eye contact

Liked people

Check all that apply

Colicky and irritable

Daily feeding problems

Frequent sleeping problems

Often restless

Overactive

Did not enjoy cuddling

Tantrums, head banging

Accident prone, dare devil

Uncoordinated

Avoided eye contact

Disliked contact with others

EARLY EXPERIENCES

Please check all of the experiences that fit for your child during infancy and childhood.

Check all that apply

Death of a family member

Death of a pet

Best or close friend moved

Eating issues

Stomachaches

Fire setting

Accident

Physical assault

Check all that apply

Death of a friend

Moved

Nightmares

Frequent headaches

Frequent illnesses

Torturing animals

Witnessed violence

Sexual Assault

If death of a family member checked, please note who by role to child and at what age. Example: Mother, when child was 11 years old.

CHILD'S TRAITS

Child’s Temperament, Traits, and Social Interactions.

Is your child overactive?

Yes

Please describe

Does your child have trouble paying attention?

Yes

Please describe

Does your child have trouble staying with an activity?

Yes

Please describe

Does your child have fluctuating moods?

Yes

Please describe

Does your child get frustrated easily?

Yes

Please describe

Are your child’s emotional responses generally unpredictable?

Yes

Please describe

Does it take your child a long time to warm up to new situations/people?

Yes

Please describe

Does your child react strongly to physical pain?

Yes

Please describe

Does your child react strongly to other things?

Yes

Please describe

Problem Areas

Please check all that apply to your child.

Check all that apply

Discipline

Risky behaviors

Mean, or aggressive

Irritable

Cries easily

Impulsive

Tease/bully others

Peer rejection

No friends

Bossy or controlling

Trouble making friends

Check all that apply

Temper or fighting

Argumentative

Angry

Manipulative

Shy or timid

Worrier

Fears making mistakes

Has been or is being bullied

Popular with peers

Few friends

Loses friends

Please describe any of the checked items above with more details.

FAMILY TRAITS

Has your child or any of your family members struggled with any of the following?
Check all that apply.

Depression, or sadness

Child current

Child in the past

Mother

Father

Sibling

Other member

Anxiety, Excessive worries, irritability, decreased concentration/focus, restless easily fatigued

Child current

Child in the past

Mother

Father

Sibling

Other member

Obsessions/Compulsions

Child current

Child in the past

Mother

Father

Sibling

Other member

Tic: Vocal/Motor

Child current

Child in the past

Mother

Father

Sibling

Other member

Headaches

Child current

Child in the past

Mother

Father

Sibling

Other member

Suicidal Thoughts

Child current

Child in the past

Mother

Father

Sibling

Other member

Attempted Suicide

Child current

Child in the past

Mother

Father

Sibling

Other member

Learning Disability

Child current

Child in the past

Mother

Father

Sibling

Other member

ADD/ADHD

Child current

Child in the past

Mother

Father

Sibling

Other member

Problems with Anger

Child current

Child in the past

Mother

Father

Sibling

Other member

Problems with Assertiveness

Child current

Child in the past

Mother

Father

Sibling

Other member

Opposition/Defiance (child/adolescent only), loses temper, argues with adults, actively defies adults, deliberately annoys others, blames others for own mistakes, spiteful, vindictive, resentful, easily annoyed.

Child current

Child in the past

Mother

Father

Sibling

Other member

Conduct (child/adolescent only), Bullies, threatens, starts physical fights, physically cruel to people/animals, has stolen, has set fire(s), property destruction, lying, cons, stays out at night w/o parents.

Child current

Child in the past

Mother

Father

Sibling

Other member

Problems with the law

Child current

Child in the past

Mother

Father

Sibling

Other member

Schizophrenia/Psychosis

Child current

Child in the past

Mother

Father

Sibling

Other member

Alcohol Use

Child current

Child in the past

Mother

Father

Sibling

Other member

Drug Use

Child current

Child in the past

Mother

Father

Sibling

Other member

Eating Disorder

Child current

Child in the past

Mother

Father

Sibling

Other member

Abuse/Neglect

Child current

Child in the past

Mother

Father

Sibling

Other member

Self Harm Behaviors

Child current

Child in the past

Mother

Father

Sibling

Other member

Social Anxiety

Child current

Child in the past

Mother

Father

Sibling

Other member

Sleep Problems

Child current

Child in the past

Mother

Father

Sibling

Other member

Dreams & Nightmares

Child current

Child in the past

Mother

Father

Sibling

Other member

Phobias/Fears

Child current

Child in the past

Mother

Father

Sibling

Other member

Trauma Witnessed/Experienced

Child current

Child in the past

Mother

Father

Sibling

Other member

Other - please describe.

Social Media and Technology

Sources and time your child spends on social media.

Check all devices your child uses

Computer

iPad/Tablet

Cell phone

Gaming system

Do you montor use of devices

Total weekly hours on social media

Total weekend hours on social media

Indicate social platforms your child uses

Emailing

Texting

Gaming

Facebook

Instagram

Twitter

SnapChat

You tube

Tiktok

Total hours spent watching television

Total hours spent on video games

REVIEW

Please review your answers and sign this form to indicate you have answered questions to the best of your ability.

Are there any other areas of concerns you want to provide more information about your child?

I have read and agree to the Terms and Conditions

Your Signature

Sign Here